Provider Demographics
NPI:1891157046
Name:FERNANDES, GRENVILLE RIO-JOHN (MD)
Entity Type:Individual
Prefix:
First Name:GRENVILLE
Middle Name:RIO-JOHN
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 E 75TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2717
Mailing Address - Country:US
Mailing Address - Phone:317-588-7130
Mailing Address - Fax:317-588-7133
Practice Address - Street 1:6330 E 75TH ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2717
Practice Address - Country:US
Practice Address - Phone:317-588-7130
Practice Address - Fax:317-588-7133
Is Sole Proprietor?:No
Enumeration Date:2016-03-27
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01084046A208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300039070Medicaid